This protocol is for a prospective multicenter randomized clinical trial, which began in March 2025 and is expected to end in November 2025. This protocol outlines our plan to assess the knowledge and skill enhancement of a pilot intervention across three centers: Hasanuddin University (Makassar, Indonesia), Padjajaran University (Bandung, Indonesia), and Universitas Sumatera Utara (Medan, Indonesia). A total of 90 dental students participated in the study (G*Power effect size 0.6, statistical power 85%). All participants enrolled in this study were randomly assigned to either an intervention group (n=15) or a control group (n=15) within each center. We used the block randomization method for the allocation of participants.

Two independent reviewers (an oral and maxillofacial surgeon) were assigned to evaluate and score each participant’s pretest and posttest sheets (Multimedia Appendix 1). Before data collection, the assessors underwent a calibration session to standardize the answer key for the multiple-choice questions (MCQs) and ensure consistent scoring. During the study, the assessors were blinded to the participants’ identities and allocation status, as they did not have access to names or group assignments. A final score for each participant was calculated.

Additionally, the reviewer will assess the participants’ training videos, focusing on training time completion, in-app lag or confusion, and skipped steps, to evaluate participants’ performance during training.

Before participating in this study, the research assistant explained the trial flow and procedures for both the IR-based training and the conventional training. All participants will receive a brief introduction to the study and will have the opportunity to ask questions about the study procedures. After the participants provide their written informed consent (Multimedia Appendix 2), their basic health status will be recorded (Multimedia Appendix 3). Participants who are unable to give consent will be excluded from the study.

Participants will be enrolled from the Universitas Sumatera Utara, Hasanuddin University, and Padjajaran University. Eligible participants must be 20 years or older and be currently enrolled in their third year of dental school or have completed a minimum of seven semesters. They should have completed tutorials on both the open and closed methods of tooth extraction, possess knowledge of medical technology, and be capable of providing informed consent. Individuals who are unable to engage with virtual content for a minimum duration of 10 minutes while using an HMD will be excluded from participation.

Individuals who are unable to provide informed consent, possess health complications, display symptoms of cybersickness (eg, dizziness, disorientation, or vomiting) during training sessions, or are unable to complete the training session are excluded from participation. Additional exclusion criteria encompass a history of hallucinations, panic attacks, seizures, phobias (including claustrophobia and acrophobia), or active alcohol or substance abuse.

Before the intervention, two oral and maxillofacial surgeons from each center will follow a comprehensive meeting held in Hasanuddin University, Makassar, to ensure consistent delivery of the interventions across centers and instructors. In addition, a facility assessment will be reported during the meeting to ensure that each center can deliver the intervention method using the same protocol.

Participants will be given a brief introduction and explanation of the study’s purpose. A research assistant will present the informed consent both in writing and verbally. This study has adopted standardized procedures for tooth extraction, using both open and closed methods.

The IR training session will be conducted in a standing position, where participants role-play as dentists. The training session will focus on open and closed dental extraction for the first molar tooth (tooth 46), supervised by two oral and maxillofacial surgeons in each center. For all training sessions, the first 10 minutes will be conducted under direct supervision. Participants will then continue their sessions for the last 40 minutes using in-app assistance (sound, highlighted areas, and arrows) without additional support for the remaining session.

The IR HMD wirelessly streams to an external device and will be used during the first session to monitor the participants’ training execution and provide guidance when necessary. Participants were required to complete a full round of training. This procedure included several steps: administering local anesthesia, making an incision and separating the tooth (in open method extraction mode), luxating and extracting the tooth, performing curettage, irrigating the wound, and suturing.

Following the completion of the procedure, participants are presented with the option to either restart the training sessions by selecting the reset button or terminate the session by choosing the exit button located in the menu area.

Participants in the control group visited the Department of Oral and Maxillofacial Surgery at their origin center (Hasanuddin University, Padjajaran University, or Universitas Sumatera Utara) to receive a tutorial and hands-on laboratory instructions. Following a 10-minute lecture on the open and closed methods of dental extraction for the first molar tooth (tooth 46), participants will engage in hands-on training where they will extract artificial teeth from a phantom or mannequin, much like in the IR-based instructions. The hands-on training will have a duration of 40 minutes, starting from local anesthesia administration, gingival incision, tooth separation, tooth luxation, extraction, curettage, wound irrigation, and suturing. Tutorial and hands-on training will be guided by two oral and maxillofacial surgeons in each center. The trial flowchart is shown in Figure 1. To ensure a standardized methodology for conducting and reporting the trial, the SPIRIT (Standard Protocol Items for Intervention Trials) guidelines will be followed as shown in Table 1.

Participants who report feeling nauseated, dizzy, or disoriented, or having other health problems during a training session, will immediately be excluded from the activity. All such complaints will be recorded as cybersickness, and the occurrence of the condition will be noted for future evaluation.

This study used two distinct questionnaires to assess the participants’ perspectives toward the usability of the Immersive Reality Training System (IRTS) for dental extraction training, which were designed based on previous research [44]. The Clinical Virtual Evaluation Questionnaire is structured to gather participants’ feedback on interactive education facilitated through simulator training (Multimedia Appendix 4). This questionnaire assesses three key parameters: experience and reliability (questions 1-9), knowledge (questions 10-14), and side effects (question 15). The questionnaire comprises 15 statements, which respondents assess using a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Conversely, the Immersive Reality Neuroscience Questionnaire will assess the system’s authenticity, the participants’ experiences, and the occurrence of cybersickness (Multimedia Appendix 5). This assessment will concentrate on four principal parameters: user experience (questions 1-5), game mechanism (questions 6-10), in-app assistance (questions 11-15), and IR-induced symptoms and effects (questions 16-20). The questionnaire is composed of 20 questions, which participants will answer using a Likert scale ranging from 1 (extremely poor) to 7 (extremely good). To ensure that the system’s quality is deemed suitable for use without causing significant cybersickness, each parameter must meet a minimum threshold (cutoff) score of 25 [45].

To assess the practical skills and knowledge acquired, participants from both the intervention and control groups will be required to complete a pretest prior to the training and a posttest following the training session. The MCQs were administered in accordance with the reference textbook used by the Faculty of Dentistry, as outlined in the dentistry curriculum [46]. The scores ranged from 0 to 100, and the test scores of both groups were subsequently compared. The MCQs are centered on the procedural steps, instrumentation, and guiding principles pertinent to dental extraction. This examination is an established component of the curricula at Hasanuddin University, Padjajaran University, and Universitas Sumatera Utara, aimed at assessing students’ practical competencies and theoretical knowledge. Consequently, a comparative analysis test will be used to evaluate the scores obtained from the clinical skill training between these two groups.

Additionally, the performance of participants will be evaluated through recorded video training and will be assessed by an independent reviewer, focusing on training time completion, in-app lag or confusion, and skipped steps. The confidential paper-based data of participants will be securely stored in a locked storage unit at the study site, while electronic data will be maintained in a protected folder on a server at Hasanuddin University, Makassar, Indonesia.